Correlation of ankle-wrist pressure index with ankle-brachial pressure index to assess lower limb perfusion in diabetic foot ulcer: a pilot study.

OBJECTIVE: The presence of peripheral artery disease (PAD) in patients with diabetic foot ulcers (DFUs) is a significant risk factor for chronicity and amputation. Ankle-brachial pressure index (ABPI) is a screening tool for PAD. Brachial systolic pressure measurement, used as a denominator in the calculation of ABPI, produces inaccurate results in patients with obesity and the presence of heavy clothing. The wrist, however, is easily accessible, and the ankle-wrist pressure index (AWPI), if comparable with ABPI, may be useful in screening selected patients. This study aimed to assess the efficacy of AWPI in diagnosing perfusion in DFUs and compare it to ABPI in patients with DFUs. METHOD: ABPI and AWPI were calculated by measuring systolic blood pressure in the arteries of the ankle, arm and wrist with a handheld Doppler. Actual perfusion was determined by the presence or absence of PAD by duplex ultrasound. RESULTS: A total of 46 lower extremities in 41 patients were studied. The prevalence of PAD was 61%. Duplex ultrasound confirmed that the sensitivity of ABPI and AWPI in detecting PAD in patients with DFUs was 67.9% and 71.4% respectively, whereas the specificity of ABPI and AWPI was 94.4% and 88.9% respectively. On receiver operating characteristic analysis, the area under the curve of ABPI and AWPI was 0.804 and 0.795, respectively. A statistically significant positive correlation between ABPI and AWPI was found (r=0.986; p<0.001). CONCLUSION: There was a good correlation between ABPI and AWPI over a wide range of values. ABPI and AWPI may have a similar role in predicting perfusion in patients with DFUs. AWPI could be used in place of ABPI in selected patients in whom measuring ABPI may be difficult. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Current standards of surgical management of gastric cancer: an appraisal.

PURPOSE: Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC. METHODS: We conducted a systematic search on the PubMed database for studies on the management of GC. RESULTS: Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach. CONCLUSION: Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.

Emergence of Unusual Microorganisms in Microflora of Pilonidal Sinuses: A Multiple Case Series.

PURPOSE: Recent reports have noted an emergence of unusual organisms in microflora of pilonidal sinus (PNS); this study was undertaken to identify the primary microbial flora associated with infected primary PNS over a period of 1 year. DESIGN: A prospective multiple case series. SUBJECTS AND SETTING: A case series of 20 patients with primary PNS in a tertiary care center in Varanasi, India, was studied. The study was conducted at the Department of Microbiology and General Surgery, Institute of Medical Sciences, Varanasi, over a period of 1 year (September 2016 to July 2017). METHODS: Purulent exudate (pus) samples were collected from 20 patients with primary PNS from the discharging sinuses by aseptic methods. Samples were assessed for aerobic and anaerobic flora by conventional culture and molecular methods. Antimicrobial susceptibility testing was done for bacterial isolates. Bacterial diversity was compared with the demographic and clinical profile of the sinuses by multiple correspondence analysis. RESULTS: Of the total cases, 11 (55%) had purulent discharge, among which all showed polymicrobial flora. The ratio of aerobic to anaerobic organisms was 1:2 (16/32). Escherichia coli (E. coli, 4, 36.36%) and Enterococcus faecalis (E. faecalis, 4, 36.36%) were commonly isolated. Bifidobacterium was the most frequent anaerobe. Detailed molecular analysis revealed the presence of Kocuria flava as an unusual pathogen. On statistical analysis, factors like male gender, increased body mass index, absence of hair in sinus, presence of features of hirsutism, and absence of Fusobacteria were closely associated with one another in these PNS cases. CONCLUSIONS: The case series revealed the predominance of anaerobes in primarily infected PNS cases. Bifidobacterium spp and unusual pathogens like K. flava were among the emerging pathogens in infected PNS. Use of better molecular diagnostic facilities in addition to the conventional methods might enhance the verified diversity of microorganisms in such cases.

An appraisal of vascular endothelial growth factor (VEGF): the dynamic molecule of wound healing and its current clinical applications.

Angiogenesis is a critical step of wound healing, and its failure leads to chronic wounds. The idea of restoring blood flow to the damaged tissues by promoting neo-angiogenesis is lucrative and has been researched extensively. Vascular endothelial growth factor (VEGF), a key dynamic molecule of angiogenesis has been investigated for its functions. In this review, we aim to appraise its biology, the comprehensive role of this dynamic molecule in the wound healing process, and how this knowledge has been translated in clinical application in various types of wounds. Although, most laboratory research on the use of VEGF is promising, its clinical applications have not met great expectations. We discuss various lacunae that might exist in making its clinical application unsuccessful for commercial use, and provide insight to the foundation for future research.

Significant presence of biofilm-producing gut-derived bacteria in anal fistula of chronic duration.

Fistula-in-ano though not a life-threatening condition, yet its symptoms often significantly impact patients' social, intimate, and work lives. There is an established role of bacterial microflora in acute infections. However, we proposed that biofilm-forming organisms might be present in the microflora of anal fistula of prolonged duration. This aspect has rarely been studied earlier. Therefore, the study describes the microbiology of anal fistula and the biofilm-forming capacity of the isolated organisms. A total of 30 patients were included in the study as per the criteria. Anal fistula tissue sample, tissue fluid, and blood samples were collected from each individual. The collected specimens were detected for the presence of aerobic and anaerobic microflora through standard microbiological method and polymerase chain reaction. Furthermore, the role of biofilm formation by microtitre plate assay and serum matrix metalloproteinases-9 was also studied. The result showed significant predominance of gut-derived microflora with high-to-moderate biofilm-producing ability in anal fistulas of prolonged duration. The study emphasises the presence of biofilm-forming bacteria in chronic, non-healing fistula.

Cracking the silent gallstone code: Wait or operate?

The widespread availability of abdominal ultrasound has revealed the common occurrence of asymptomatic gallstones. While the treatment for symptomatic gallstones is clear, the benefits of minimally invasive laparoscopic cholecystectomy have sparked debate about the best approach to managing silent gallstones. The potential for asymptomatic gallstones to become symptomatic or lead to complications complicates the decision-making process regarding surgical intervention, as it's uncertain when or which patients might develop complications. Consequently, risk stratification appears to play a critical role in guiding decisions about silent gallstones. However, there is no definitive evidence to direct management, and a consensus-based on high-quality evidence is yet to be established.

Duodenocolic and Cholecystocolonic Fistula: A Case Report of an Unusual Presentation.

Laparoscopic cholecystectomy is the established standard of care for addressing symptomatic gallstones, typically representing a straightforward and uncomplicated surgical procedure. However, patients exhibiting variant anatomy or local inflammation can present challenges to the surgeon, potentially leading to complications. In this context, we present the case of a 55-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallstone disease at a different medical facility. Postoperatively, she was diagnosed with a case of duodenocolic fistula and cholecystocolonic fistula. Conservative treatment ensued with intravenous antibiotic administration, as well as enteral and parenteral feeding. Diagnosing cholecystocolonic fistula before surgery proves challenging, even with modern diagnostic and imaging tools. Despite its significance, there is limited information in the literature regarding the management of this infrequent finding. The approach to diagnosis and management is elaborated upon in the case report.

Male Breast Cancer: An Updated Review of Patient Characteristics, Genetics, and Outcome.

Male breast cancer (MBC) is a rare entity, underrepresented in population studies and clinical trials, resulting in management of MBC to be informed by current research on female breast cancer (FBC). A literature review was conducted by accessing relevant articles on 2 databases, by searching keywords "male breast cancer". A total of 29 articles from year 2011 to 2022 were selected for this review. The authors found that male breast cancer generally occurs later in life with higher stage, higher grade, and more estrogen receptor (ER) positive tumours. Most of the studies noted the mean age for MBCs at the time of presentation as >60 years. Risk factors for male breast cancer include family history, obesity, lower physical activity, and syndromes like the Klinefelter syndrome. Positive family history is much higher in MBC compared to FBC (30.9 vs. 18.4%). BRCA 2 cancers constitute a higher proportion compared to FBCs. A lot of genetic mutations have been observed. Some show promise to assess disease-specific survival and proliferative rate like TWIST1 and RUNX3, among others. MBCs usually present with a palpable lump in central region, with a bigger size and chance of nodal involvement and metastasis compared to FBCs. They are mostly infiltrating ductal type and hormone receptor positive, with worse histological grade. Treatment usually follows the same principles as FBCs (systemic therapy, surgical excision, and radiotherapy), with poorer prognosis to same treatment approach, possibly owing to its advanced stage at presentation. This is a rare entity which requires further research to ascertain need for different management approach than FBCs.

Heavy and trace metals in carcinoma of the gallbladder.

BACKGROUND: Carcinoma of the gallbladder is the commonest malignancy of the biliary tract in northern India The etiologic relation of specific metals (heavy and trace) and their compounds to neoplasia has been a topic of investigation for some time but not adequately described for carcinoma of the gallbladder. The aim of the present study was to evaluate the relation of heavy and trace metals to this malignancy. METHODS: The levels of selenium, zinc, copper, manganese, cadmium, chromium, lead, and nickel were estimated in serum, bile, gallstones, and gallbladder tissue using atomic absorption spectrophotometry. The tests were carried out in 30 patients with gallbladder cancer and 30 sex-matched patients with cholelithiasis. RESULTS: Selenium and zinc levels were significantly reduced (p < 0.001) and copper concentration was found to be significantly higher (p < 0.001) in serum, bile, and gallbladder tissue from patients with carcinoma of the gallbladder. Lead, cadmium, chromium, and nickel levels were elevated in serum and bile in patients with carcinoma of the gallbladder. CONCLUSIONS: The present study demonstrated a significant decrease in serum, biliary, and tissue levels of selenium and zinc but increased copper, lead, cadmium, chromium, and nickel levels in patients with carcinoma of the gallbladder, indicating a strong relation between the concentrations of these metals and gallbladder cancer.

"Hurricane-like" Presentation of a Recurrent Marjolin's Ulcer in a Young Female.

Marjolin's ulcer (MU) with rapid progression and multiple distant metastases is rare. We report a case of an MU of the thigh developing in a postburn scar, which after successful R0 resection developed multiple bony and visceral metastasis to femur, vertebra, skull, lung, and liver within 3 months of excision. We highlight the "hurricane-like" recurrence in an MU, which is unusual for the metachronous disease. We stress that MUs, unlike conventional wisdom, need a thorough metastatic workup at presentation, and prognostication of a possible rapidly progressive course after surgery which may lead to grave prognosis and mortality.

Perception, perceived scope, and potential barriers towards developing nurse practitioners cadre among health care providers and beneficiaries: A pilot study from Northern India.

BACKGROUND: The role of nurse practitioner (NP) emerged in early 1965 when general practitioners began working with nurses. Evidence across the world highlights the benefits achieved by the NP role. The Indian Nursing Council (INC) implemented a country-wide NP in critical care (NPCC) program with the approval of the ministry of health and family welfare (MoHFW) in 2017. The NP role is in its infancy in India. Hence, there is a need to assess the perception among beneficiaries and healthcare personnel. This study was conducted to assess the perception, perceived scope, and potential barriers for developing the role of NPs in India among beneficiaries and healthcare providers. MATERIAL AND METHODS: A descriptive, cross-sectional pilot study was conducted at AIIMS Rishikesh, Uttarakhand, India, among 205 participants (84 beneficiaries, 78 nurses, and 43 physicians) using a proportionate stratified random sampling technique. Likert scales and socio-demographic sheets were used to assess the perception, perceived scope of practice, and potential barriers in developing a NP cadre in India. Descriptive and inferential statistics were used for analyzing data. RESULTS: The mean age of beneficiaries was 37.98, nurses was 27.58, and physicians was 28.13 years, respectively. 121 (61%) of participants were highly favored, and 77 (38%) were in favor of developing NP cadre in India. They considered it to be necessary, feasible, and acceptable in India. The feasibility and necessity of the perception domain were highly significant (P < 0.001 and P < 0.003, respectively). Nurses (mean ± SD: 35.36 ± 3.55) considered that NPs could have a wide range of practice followed by beneficiaries (mean ± SD: 38.17 ± 3.68) than physicians (mean ± SD: 34.75 ± 5.95). Lack of awareness, the nonexistence of cadre structure, lack of acceptance of the role of physicians, and lack of clear policy were the key potential barriers to develop an NP cadre in India. CONCLUSIONS: In this study, participants had favorable views on employing NPs in India; thus, this role will improve healthcare access for beneficiaries. NPs can carry out a wide range of practices.However, a lack of awareness, no cadre structure, and a lack of a clear policy may hinder the development of the NP cadre in India.

Locally Advanced Rectal Cancer: What We Learned in the Last Two Decades and the Future Perspectives.

The advancement in surgical techniques, optimization of systemic chemoradiotherapy, and development of refined diagnostic and imaging modalities have brought a phenomenal shift in the treatment of the locally advanced rectal cancer. Although each therapeutic option has shown substantial progress in their field, it is finding their ideal amalgamation which has baffled the clinician and researchers alike. In the effort to identifying the perfect salutary treatment plan, we have even shifted our attention from the trimodal approach to non-operative "watchful waiting" to more recent individualized care. In this article, we acknowledge the scientific progress in the management of locally advanced rectal cancer and compare the opportunities as well as the obstacles while implementing them clinically. We also explore the current challenges and controversies surrounding the multidisciplinary approach and highlight the new trends and recent advances with an ultimate goal to improve the patients' quality of life.

Wound pH and Surface Temperature as a Predictive Biomarker of Healing in Diabetic Foot Ulcers.

AIM: To monitor wound pH and surface temperature as predictors of wound healing in diabetic foot ulcers (DFU). METHODS: Prospective, observational, time-bound study of 18 months, enrolling patients aged 18 to 60 years with uninfected DFU. The wound was assessed at baseline and after that, every week for 4 weeks according to the leg ulcer measurement tool (LUMT). Concurrently, wound surface pH and temperature were measured. The data were analyzed using descriptive statistics, and a P-value < .05 was considered statistically significant. RESULTS: Fifty-four patients with DFU were included in the study with a mean age of 55 years and a male to female ratio of 1.57. The wound showed progressive improvement, a maximum mean LUMT score of 48.89 (± 2.81) at the initial evaluation and decreased progressively to the mean of 19.80 at week 4 (± 3.43), both of which were statistically significant (P-value < .001). Similarly, the median wound pH progressively reduced from 7.7 at baseline to 7.20 in the fourth week, and median wound temperature decreased from 90°F (32.22 °C) at baseline to 85°F (29.44 °C) in the fourth week, both of which were statistically significant (P-value < .001). CONCLUSION: Progressive and significant change in wound pH to acidic and drop in wound surface temperature, both corresponding to improvement in the status of DFU, maximum at 4 weeks, make them valuable predictors of wound healing. However, further, more extensive studies are required to establish a concrete relationship.

Biofilm and wound healing: from bench to bedside.

The bubbling community of microorganisms, consisting of diverse colonies encased in a self-produced protective matrix and playing an essential role in the persistence of infection and antimicrobial resistance, is often referred to as a biofilm. Although apparently indolent, the biofilm involves not only inanimate surfaces but also living tissue, making it truly ubiquitous. The mechanism of biofilm formation, its growth, and the development of resistance are ever-intriguing subjects and are yet to be completely deciphered. Although an abundance of studies in recent years has focused on the various ways to create potential anti-biofilm and antimicrobial therapeutics, a dearth of a clear standard of clinical practice remains, and therefore, there is essentially a need for translating laboratory research to novel bedside anti-biofilm strategies that can provide a better clinical outcome. Of significance, biofilm is responsible for faulty wound healing and wound chronicity. The experimental studies report the prevalence of biofilm in chronic wounds anywhere between 20 and 100%, which makes it a topic of significant concern in wound healing. The ongoing scientific endeavor to comprehensively understand the mechanism of biofilm interaction with wounds and generate standardized anti-biofilm measures which are reproducible in the clinical setting is the challenge of the hour. In this context of "more needs to be done", we aim to explore various effective and clinically meaningful methods currently available for biofilm management and how these tools can be translated into safe clinical practice.

Wandering Spleen and Acute Gastric Volvulus in an Elderly Woman with Acute Abdomen: A Case Report.

Gastric volvulus is an uncommon clinical condition with the potentially life-threatening complication of acute gastric necrosis. A wandering spleen may also be associated with gastric volvulus and can produce a diagnostic dilemma as the cause of an acute abdomen. We present a case of an elderly woman who presented with acute abdominal symptoms. She did not have the classical Borchardt triad to diagnose gastric volvulus and had a coexisting wandering spleen. Although torsion and ischemia of the wandering spleen were initially thought to be the cause of acute abdomen, a subsequent contrast-enhanced CT (CECT) scan confirmed a coexistent mesenteric-axial gastric volvulus with gangrenous changes. We present this case to highlight a rare combination of pathologies, either of which can confuse the diagnosis or cause a delay in management. Early diagnosis with CECT is emphasized, and segmental resection is feasible when the rest of the viscus can be preserved.

Intestinal Obstruction Due to an Incarcerated Obturator Hernia: A Case Report and Review of the Literature.

An obturator hernia (OH) is a rare form of pelvic hernia in which the abdominal contents protrude through the obturator canal. Malnourished, frail, and multiparous elderly females are at risk of an OH. Preoperative diagnosis of obturator hernia is challenging because of non-specific symptoms. Most of the cases of OH reported in the literature are diagnosed during a laparotomy for acute intestinal obstruction. However, a contrast-enhanced computed tomography (CECT) scan of the abdomen is the best diagnostic investigation for OH. The morbidity and mortality are high because of the associated complications. We report a case of an obturator hernia in a 79-year-old cachectic female with features of acute intestinal obstruction and the usefulness of a CT scan in the preoperative diagnosis. Early diagnosis and treatment are the keys to preventing disastrous complications.

Superior Mesenteric Artery Syndrome as a Rare Cause of Postoperative Intractable Vomiting: A Case Report.

Background: Superior mesenteric artery syndrome is a very rare cause of proximal intestinal obstruction. The objective of this clinical case report is to highlight that this unusual condition can occur in the early postoperative period and medical management may completely cure the condition. Clinical Case: A middle-aged female who was being treated for pulmonary tuberculosis underwent exploratory laparotomy with limited ileal resection and a loop ileostomy for multiple ileal perforations. Postoperatively, she was restarted on anti-tubercular drugs (ATD) but developed a drug reaction, recurrent bilious vomiting, and jaundice and ATD had to be stopped. But her vomiting did not abate and she progressively developed septicemia. An abdominal CT scan diagnosed Wilkie's syndrome, and she was managed non-operatively by decubitus, parenteral nutrition, and nasojejunal tube feeding supplemented with prokinetics and antibiotics. But her sepsis did not resolve. Intraoperative histopathology suggested Candida infection, and she recovered only after systemic antifungal therapy. Discussion: Debilitation conditions like tuberculosis cause weight loss and loss of intra-abdominal fat pad, which is known to precipitate SMA syndrome. However, its presentation in the early post-operative period is rare. Symptoms may vary from non-specific abdominal fullness and weight loss to features of acute bowel obstruction. CECT of whole abdomen can help in confirming the diagnosis. SMA syndrome is often not considered in differential diagnosis and can delay treatment. Medical management is the mainstay treatment option, although surgery is reserved for cases, which fail medical treatment. Conclusion: High suspicion is needed to diagnose SMA syndrome in the postoperative period, which precipitates with intractable bilious vomiting. Medical management may be curative. The precipitating factor for SMA syndrome should also be addressed to improve the overall patient outcome.

Poor Glycemic Control Is Associated With Lower Interleukin-2 (IL-2) Levels and Low Macrophage Viability in Chronic Diabetic Foot Ulcers (DFUs).

Low macrophage viability in chronic diabetic foot ulcers (DFUs) may lead to inadequate interleukin (IL) expression and the persistence of infection. This study evaluates the association between macrophage function, IL-2 expression, and wound microflora in chronic DFUs. Diabetic patients with DFUs (group 1, n = 40) and without DFUs (group 2, n = 40) were compared for macrophage function in serum by viability testing. Immunological response was measured by serum IL-1ß, IL-2ß, and IL-10 levels. The aerobic and anaerobic microflora of the DFUs were assessed by culture and molecular methods. Demographic, clinical, and biochemical factors were statistically analyzed by χ2 test and Student t test. Multiple correspondence analysis (MCA) was used to detect the pattern of association between glycosylated hemoglobin (hemoglobin A1c), serum IL-2 levels, and macrophage viability. Of the total DFU cases, 22 (55%) showed the presence of polymicrobial microflora. Low macrophage viability with predominant Gram-negative flora was seen in 10 (25%) cases in group 1. Serum IL-2 levels were significantly lower (P = .004) in patients in group 1 along with elevated levels of hemoglobin A1c (P = .038). MCA showed an association between low viability of macrophages and lower IL-2 levels and elevated hemoglobin A1c levels with lower serum IL-2 levels. As compared to group 2, the low viability of macrophages was significantly associated (P = .007) with lower IL-2 levels in group 1. Elevated hemoglobin A1c levels are strongly associated with lower IL-2 levels and low macrophage viability. This might be a contributing factor to the persistence of infections in chronic DFUs.

Wound Healing in the Golden Agers: What We Know and the Possible Way Ahead.

While "population aging" is an accomplishment that deserves acclamation, it is in itself a tremendous challenge. Age-related skin changes, impaired wound healing, and concurrent comorbidities are the deadly triad that contribute most to the development of nonhealing chronic wounds in the elderly. This imposes enormous medical, social, and financial burden. With the rising trend in the aging population, this problem is likely to exacerbate unless multidisciplinary, rapt wound care strategies are developed. The last decade was dedicated to understand the basic biology underlying the wound healing process but most in vitro and animal model studies translated poorly to human conditions. Forthcoming, the focus is on the development of diagnostic and therapeutic strategies to improve healing in this vulnerable age group. Further, understanding the complex pathobiology of cellular senescence and wound healing process is required to develop focused therapy for these "problem wounds" in the elderly.

Psychological Stress on Wound Healing: A Silent Player in a Complex Background.

Stress is hard to define and is further complicated by varied perceptions in the population and differing responses in different situations. Psychological stress brings about certain physiological changes through manipulation of the neural, humoral and immunological systems. Observational studies have showed that fear and anxiety before surgery can complicate normal wound healing. Two different pathways appear to be involved: one directly through hypothalamic-pituitary-adrenal axis and sympathetic-adrenomedullary axis, and another indirectly through negative psychological stressors such as anxiety, depression and social isolation. The pathogenesis includes decreased expression of pro-inflammatory cytokines, resulting in poor angiogenesis, matrix regeneration and delayed healing. Prolonged immunological activation in itself is a stressor and can precipitate a sickness behaviour syndrome manifested by disturbed sleep, anorexia, reduction in activity, increased responsiveness to pain and addiction to alcohol and tobacco. It has been observed that cortisol release suppresses pro-inflammatory cytokine release, while down-regulation of cortisol causes unabated inflammatory response. In individuals with chronic wounds, on the other hand, it is thought that physical stress has different effects such as foul odor, pain, exudate and social and familial isolation, which may act independently as psychological stressors. This article attempts to appraise the influence of psychological stress on the immunological system and its effect on wound healing.